Beauty Tips: Banish Acne

The hormonal truth of adult-onset acne and how to deal

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Late one Manhattan afternoon at a Nespresso bar heady with fresh-brewed java and demitasse-sipping foreigners, I met with Maura, 29, a single musician who lives in Brooklyn. While I slugged back double espresso cappuccinos with shameless heaps of sugar, Maura nursed a chamomile tea while recounting
her three-year odyssey of dermatological horror, her mellifluous voice belying the gripping drama she was describing. Naturally, given my obsession with all matters epidermal, I was transfixed. Scrutinizing her face—brown doe eyes, rosy lips, and a dewy complexion framed by cascading brunette locks—I could hardly believe what she was saying, so at odds was it with the fresh-looking pretty before me.

But in August 2005, despite never having acne as a teenager or so much as a smattering of blackheads to warn her, Maura literally awoke one morning to find that her face had turned medieval on her: From forehead to jawline, her skin had erupted in oozing pimples and swollen sebaceous cysts that made it hurt even to smile. As they healed, defiant red scars marked their wake. They also left invisible (and all the more pernicious for it) scars on Maura's psyche: She felt paranoid, alienated, and downright awkward in her own indisputably undesirable skin.

"As a performer, I have to be confident and focused and feeling good," Maura told me. "The acne made me feel embarrassed. I tried to tell myself I was being superficial. It didn't work. I would think everyone was looking at these huge zits when I was onstage. I was self-conscious when I was dating. I didn't notice any triggers or patterns—no matter what I did, I always had acne."

Maura's was a late-onset case, and though more severe than most, it was hardly a rarity. According to the American Academy of Dermatology, acne is the most common skin disorder, affecting 40 to 50 million people in the United States, from teenyboppers and celebutantes to soccer moms and barmaids well past their prime. While adolescent boys are hit harder than teenage girls, after puberty, adult women are the main victims, their zits occurring more frequently and more numerously—as well as proving more resistant to treatment—than those of adult men.

But not all adult female acne is equally opportunistic; the more aggressive manifestations of the disease—yes, acne is deemed a disease by dermatologists—can resist a multitude of cures because
the remedies don't treat the root of the problem.

Having no idea to what lengths she would eventually have to go to find salvation for her raging complexion, Maura began regularly raiding the skin-care aisles of CVS, praying for relief from a power higher than pimples. She pinned her hopes on over-the-counter products containing benzoyl peroxide, an antibacterial ingredient, or salicylic acid, a mild compound derived from willow bark that causes the outer layer of dead skin cells to slough off, unplugging blocked pores. But despite a mounting pile of lotions, scrubs, soaps, serums, gels, creams, peels, and pads, Maura's face remained a festering mess.

Did Proactiv hold the solution? So promised the infomercial that seduced Maura into making that 1-800 call. But after giving the three-step treatment a two-month trial, she conceded another defeat. Next came the herbal panaceas: tea-tree oil, aloe, and lavender. She concocted facial masks of eggs, oatmeal, grapefruit, lemon, and yogurt—ingredients ultimately better suited to a healthy breakfast than to hard-core blemish busting.

Once she gave up on the fun-with-food phase, Maura went old school: At bedtime, she smeared Maalox over her face and dabbed toothpaste on her pimples. In the morning, after washing her face, she coated her acne with Preparation H to reduce the inflammation. When the ointment was absorbed, she rinsed her face and dotted her pimples with Visine to minimize their redness—all of which served as the primer for her daily basting of makeup to camouflage her tortured pores.

Little did she know she was probably aggravating the problem. "These things can make acne worse by blocking the pores, and you can even get a reactive flushing after the Visine, which is a vasoconstrictor,
wears off, making your skin redden due to the constriction and dilation of the capillaries," says David Colbert, MD, of New York Dermatology Group.

At one point, having heard acne-be-gone miracle tales about the Living and Raw Foods diet, Maura embraced a daily menu of uncooked, unheated, unprocessed organic comestibles. And glory be! Three weeks later, her skin was smooth and glowing. But after three months of subsisting on lettuce wraps, parsley soup, zucchini chips, barley cookies, and celery coolers, she threw in the towel, or rather her juicer. There are reasons why God made doughnuts. Maura slipped back to feasting on the dead and the cooked—a return accompanied by the resurgence of her acne.

Because Maura felt she couldn't afford to see a dermatologist without health insurance, she wasted a year and more than $1,000 on all these treatments, to no avail. Then she came across a newspaper ad for a team headed by New York City dermatologist Neil Sadick, MD, who sought participants for an adult-acne study to test Omnilux blue-light therapy, which kills acne-causing bacteria. All a guinea pig had to do was to sit back for a painless 20-minute session with a light source beaming on her face.

After three weeks of Omnilux sessions, Maura's complexion improved, but because blue-light therapy
requires twice-a-week exposure for four to six weeks, followed by monthly visits, she couldn't afford to continue them (at Sadick Dermatology Group, one treatment costs $100 to $175 and a package of eight is $800 to $1,100). When a new rash of bedeviling blemishes struck, Maura, now at the end of her rope, finally listened to her mother, who, having long sensed that the virulence of her daughter's acne was symptomatic of a more troubling underlying health issue, insisted that enough was enough: It was time for Maura to find some (affordable) health care, already!

At the Ryan/Chelsea Clinton Community Health Center, a federally funded clinic in Manhattan's Hell's Kitchen for the un- and underinsured, patients pay on a sliding scale. For $30, Maura got a complete physical and blood tests. The results proved two things: (1) Mothers do know best; and (2) Maura's hormones were way out of whack, which explained her raging acne.

Broadly speaking, an imbalance of hormones is the principal cause of acne. Androgens trigger the development of masculine characteristics such as facial hair and a deep voice in men; the female body also produces them in minimal amounts to sustain lean muscle mass, bone strength, and libido. But if a glitch in a woman's endocrinological system causes an androgen overload, or if her genes make her hypersensitive to the hormones, they may cause her glands to churn out excess sebum, which can mix with the dead cells at the skin's surface to plug up a pore. This becomes the breeding ground for the P. acnes bacteria, which, proliferating like mad, cause the duct to swell and rupture, leading to any of a variety of indignities, including blackheads, whiteheads, raised red bumps, and whopper-size infected subdermal nodules.

"Without those hormones, you wouldn't have acne," says Rachel Herschenfeld, MD, a dermatologist in Wellesley, Massachusetts. "That's why newborns can have it, because they were exposed to their mothers' hormones, and then it goes away until shortly before puberty, when sex hormones start to rise. Hormones are necessary, but not sufficient, to cause acne in everybody. There is no way to predict who will get acne, though a huge majority of adults will get it at some point in their lives."

For reasons that would soon be uncovered, Maura's glandular plague was brought on by abnormally
high testosterone levels. But even in normal women, the fertility cycle involves the ebb and flow of estrogen and progesterone and a testosterone spike that boosts the female libido around ovulation (nature's way of propagating the species) and—presto!—a week or so later, premenstrual acne flares up.

A 2001 study of 400 women aged 12 to 52 found that close to half of them reported acne breakouts before their period, a number that many dermatologists believe is actually much higher. "Every woman has experienced a premenstrual flare-up at some point in her life," says Audrey Kunin, MD, a dermatologist in Kansas City, Missouri, who adds, "It's the severity that varies." Another 2001 survey found that pre-period pimples become even more common in women after age 33.

Hormonal acne is tough to beat. In relatively mild cases, its symptoms may be treated effectively with over-the-counter remedies or prescription drugs: topical anti-inflammatories with an antibacterial agent such as benzoyl peroxide, an antibiotic such as erythromycin, and a retinoid, be it adapalene, tazarotene, or tretinoin—all vitamin A derivatives that clear away the skin's superficial dead cells.

Oral antibiotics are no cure-all either, thanks to widespread bacterial resistance; acne-afflicted women reported an 81 percent failure rate in a 2008 survey published in Seminars in Cutaneous Medicine and Surgery, a professional dermatology journal. The same study confirmed that Accutane, the most powerful anti-acne drug available, which works by shrinking sebaceous glands and reducing skin-oil production, can't do the job in 15 to 30 percent of adult female cases, either. In addition, both types of drugs can have uncomfortable side effects—the former sometimes causing yeast infections and upset stomach, the latter cracked, dry lips, as well as severe birth defects if taken during pregnancy.

"There's nothing cookbook about the treatment of acne," Kunin says. "I have multiple protocols depending on whether it's moderate or severe. You also have to know a patient's history. There are restrictions with every medication. All acne medicines have their problems. They have totally different side effects. There's trial and error, along with the patient's individual makeup: That's what makes acne treatment an art, not a science."

Yet doctors agree that the most effective way to knock out chronic acne is by hitting it where it counts—below the belt, so to speak: treating the causes rather than the symptoms. Since androgens
are public enemy No. 1 in the fight against pimples, hormonal therapy with an antiandrogen component (contraceptive pills or the hypertension drug spironolactone) used in combination with the aforementioned topical and oral medications can deliver a fatal one-two punch even against severe cases.

Birth control pills reduce the amount of testosterone in the body, thereby curtailing the havoc that male hormones can wreak on the sebaceous glands and, in effect, sucking the lifeblood—the sebum—out of acne. In recent years, the FDA has approved some brands for this purpose: Ortho Tri-Cyclen, Estrostep, Yasmin, and Yaz. However, oral contraceptives are not for everyone, least of all smokers, diabetics, or women with heart conditions or a history of any female-type cancer (breast, ovarian, uterine, cervical)—nor, of course, are they for those trying to get pregnant. (One widespread concern about the Pill has, however, been persuasively debunked: A study last year concluded that there is no significant weight gain caused by oral contraceptives.)

One alternative is spironolactone (Aldactone), a diuretic long prescribed for hypertension. Although not FDA-approved for acne treatment, the medication counters the effects of androgens by drying up excess sebum and has therefore been used off-label by dermatologists for about 20 years with mostly favorable results. "Any endocrinologist, gynecologist, or dermatologist," Colbert says, "should have spironolactone in their acne armamentarium." It can, however, cause monthly breakthrough bleeding and may be unsuitable for patients with kidney problems.

Finally, homeopaths such as dermatologist Howard Murad, MD, of El Segundo, California, favor treating acne with sources of phytoestrogens such as black cohosh, red clover, wild yam, and soy extracts.
Being bioidentical to estrogen, these substances, either taken as dietary supplements or applied topically via creams, offer another option for antiandrogen treatment; there is little data, however, confirming their safety or efficacy.

For Maura, the clinic prescribed a birth control pill and, to ramp up its antiacne effects, a topical antibiotic, clindamycin, as well as Retin-A Micro, a gel composed of microspheres that deliver the medication as they slowly dissolve, which makes the formula less irritating to the skin than standard Retin-A.

After three months of her clinical regimen, Maura's acne breakouts were less frequent or severe. But other noisome problems were popping up: Her weight, normally 115 to 118 pounds, had shot up to 130 pounds—all flab and no muscle—despite careful eating habits and compulsive exercise. And what to make of the utterly embarrassing and totally bizarre sprouting of coarse, black hairs on Maura's chin and neck? Had somebody put a hex on her body? Was it being possessed?

Short of an exorcism, a medical exam was in order. Early in 2008, Maura had finally landed a job with health insurance, and as she was due for a checkup, she saw Nancy Lebowitz, MD, an Upper East Side gynecologist. Still suffering from acne, along with her weight gain and facial hair, Maura answered Lebowitz's questions about her periods, which—from puberty until she'd gone on the Pill—had been erratic, occurring sometimes twice a month, at other times once every three months, and always with
very heavy bleeding, mood swings, and debilitating cramps.

Within minutes, Lebowitz made a diagnosis: Polycystic Ovary Syndrome (PCOS), a metabolic disease affecting the reproductive system in about 15 percent of women of childbearing age, according to the American Academy of Dermatology. Those with PCOS grow small, benign cysts on their ovaries and experience hormonal imbalances that can cause acne, hirsuteness, insulin resistance, and weight gain. If untreated, it can lead to infertility, diabetes, and heart disease.

"People who have the syndrome secrete too much insulin when they eat carbohydrates, which causes the body to lay down fat in the midriff," Lebowitz explains. "Insulin resistance suppresses ovulation, and the ovaries begin to secrete excess testosterone. The testosterone lowers insulin resistance, which is
the body's way of trying to correct the problem. Unfortunately, the side effects of too much testosterone
include acne and facial hair. You can go to a dermatologist and get topical and oral antibiotics, but if you don't treat the underlying problem, which is a fairly common one, it won't go away." In addition to keeping Maura on the oral contraceptive, Lebowitz also put her on Ziana, a topical gel combining the antibiotic clindamycin and the retinoid tretinoin, in order to kill acne bacteria and clear her pores. Most important, however, Lebowitz advised that Maura cut back on carbohydrates to only 60 grams a day—a Spartan amount if you consider that a medium-size apple packs 20 grams. So much for doughnuts.

Sure enough, after two months of strict dieting and nightly applications of Ziana, Maura lost six pounds, and her formerly irascible complexion evolved into one of blissful peaches and cream.

"In my case, diet plays a huge role," Maura says. "My skin is clear now. I stick to whole grains, fruits, vegetables, and proteins—foods that don't cause your blood sugar to rise. And sleep plays a big part: I try to get eight to nine hours a night. Also, I do very intense cardio exercise. PCOS changed my behavior. I'm in control of my skin now, whereas when the acne kept coming back, I felt out of control," she continues. "Since my skin has cleared, it has really affected my confidence. When people compliment me on my skin, I say, `Really? Well, let me tell you what happened.' "

I was deeply envious of Maura—obviously not because of what she had gone through, but how she had overcome it. Her forbearance, self-sufficiency, and self-respect gave her the motivation to turn some pretty sorry circumstances into a wholesome way of life. She put her own needs first yet didn't seem at all selfish. Self-loving, yes, but unpretentious and aware of others.

Although my complexion is no cause for complaint, my temperament is tightly wound. Many times, I want a break from myself, which was why I wanted more of what Maura had: self-acceptance, a sunny outlook, peace of mind, restful sleep.

Could I get all that by giving up sugar in my coffee? Probably not. But it couldn't hurt to cut back. And who knows? You start with small steps and work your way up. Before you know it, you're running a mile, napping in the afternoon, and leaving your troubles for another day—a day that never even comes because you've finally put your worries to rest.

"Waiter," I impulsively called out.

"Another cappuccino, signora?"

"No, chamomile tea, please," I replied, nodding at Maura.

"And some more hot water for me," she said, smiling, as she cradled her warm cup in her hands.